37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 479637 |
Time | |
Date | 200007 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 479637 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 479638 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : company policies non adherence : published procedure |
Independent Detector | other other : person 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards contributing factor : manuals performance deficiency : inspection performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On jul/tue/00, while working aircraft xyz, I was assigned the job of replacing 6 sets of first stage fan blades on #1 engine. After receiving the blades from stores, installed each set per maintenance manual (180 degrees apart). Prior to installation, I checked all blades for obvious defects and found them acceptable to install per maintenance manual. I, after installation, attached the blade reference sheet to the job card with the positions they were installed and sold to inspection. I did not enter the blades in the component change sheet since they were not rotatable parts. Today (jul/sat/00) I discovered that serialized parts are also required to be recorded. It has been brought to my attention through discussion with management that the reference sheets for blade location I attached to the job card cannot be found to verify the position of blades. Also, we have discovered the blades that we installed did not go through receiving inspection. Since we were unaware of this, we did not fill out the inspection form normally filled out. When receiving inspection is bypassed, the inspection form would be supplied when received through stores.
Original NASA ASRS Text
Title: A B737-800 WAS DISPATCHED IN NON COMPLIANCE WITH #2 ENG FAN BLADES REPLACED WITH NO BLADE PREINSPECTION AND NO DOCUMENTATION ON BLADE LOCATION ON DISK.
Narrative: ON JUL/TUE/00, WHILE WORKING ACFT XYZ, I WAS ASSIGNED THE JOB OF REPLACING 6 SETS OF FIRST STAGE FAN BLADES ON #1 ENG. AFTER RECEIVING THE BLADES FROM STORES, INSTALLED EACH SET PER MAINT MANUAL (180 DEGS APART). PRIOR TO INSTALLATION, I CHKED ALL BLADES FOR OBVIOUS DEFECTS AND FOUND THEM ACCEPTABLE TO INSTALL PER MAINT MANUAL. I, AFTER INSTALLATION, ATTACHED THE BLADE REF SHEET TO THE JOB CARD WITH THE POSITIONS THEY WERE INSTALLED AND SOLD TO INSPECTION. I DID NOT ENTER THE BLADES IN THE COMPONENT CHANGE SHEET SINCE THEY WERE NOT ROTATABLE PARTS. TODAY (JUL/SAT/00) I DISCOVERED THAT SERIALIZED PARTS ARE ALSO REQUIRED TO BE RECORDED. IT HAS BEEN BROUGHT TO MY ATTN THROUGH DISCUSSION WITH MGMNT THAT THE REF SHEETS FOR BLADE LOCATION I ATTACHED TO THE JOB CARD CANNOT BE FOUND TO VERIFY THE POS OF BLADES. ALSO, WE HAVE DISCOVERED THE BLADES THAT WE INSTALLED DID NOT GO THROUGH RECEIVING INSPECTION. SINCE WE WERE UNAWARE OF THIS, WE DID NOT FILL OUT THE INSPECTION FORM NORMALLY FILLED OUT. WHEN RECEIVING INSPECTION IS BYPASSED, THE INSPECTION FORM WOULD BE SUPPLIED WHEN RECEIVED THROUGH STORES.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.